Reply to: Correspondence ‐ Association of spontaneous cerebrospinal fluid rhinorrhea with transverse venous sinus stenosis: a retrospective matched case‐control study

Abstract

We have read with great interest Dr Onder's correspondence 1 regarding our article. 2 In our study, we reported a higher incidence of transverse venous sinus stenosis (TSS) in a group of patients operated on for a spontaneous cerebrospinal fluid (sCSF) leak than in a control group of patients adjusted for age and sex. Dr Onder's comments focus on 3 main points. The first question that needs to be addressed is whether the diagnostic criteria for intracranial idiopathic hypertension (IIH) are appropriate for sCSF leak patients. Indeed, the diagnostic features described by Dandy in 1937, and later formulated into a set of diagnostic criteria by Smith in 1985, notably include signs and symptoms of increased intracranial pressure (headaches, nausea, vomiting, transient visual obscurations, or papilledema) and increased CSF pressure. 3 Fundoscopy or lumbar puncture opening pressure measurements were performed in only 11 of 29 patients (38%) in our series. Five of these 11 patients had clinical signs of IIH. As pointed by Dr Onder, it is therefore not possible to conclude that there was a high prevalence of IIH among the patients of our series. However, it has been clearly shown that IIH in sCSF leak patients is not systematically associated with papilledema. 4 Moreover, all of our patients had an empty sella. Given the fact that empty sella has a 90.7% specificity for the diagnosis of IIH, 5 we hypothesized that this radiologic sign favored IIH in our patients. We were able to compare pre-and postoperative magnetic resonance images (MRIs) in a subset of the patients (n = 12): the height of pituitary gland was lower after than before surgery (1.9 mm [1.7-3.2] vs 2.2 mm [1.7-3.4]; p = 0.05). This further supports the fact that empty sella is a reflection of elevated intracranial pressure.

Dural sinus septum: an underlying cause of cerebral venous sinus stenting failure and complications

“…Cerebral venous sinus stenting has been increasingly used to treat pulsatile tinnitus or intracranial hypertension caused by venous sinus stenosis. [1][2][3] However, its efficacy is undermined by a complication rate from 1.9% to 12%, mainly involving subdural haemorrhage, sinus or stent thrombosis, headache and retroperitoneal haemorrhage. [4][5][6] The latter two complications are associated with mechanical stimulation of the venous sinus wall or puncture site haemorrhage, 7 whereas the causes of the former two are still unclear.…”